Selected Issue

Consultant Vol 44 No 1

A 40-year-old man was concerned about an enlarging painless
mass on the right side of his neck that had been present
for 6 months (A). The patient reported no other health
problems; his medical history was unremarkable, and he
was taking no medications.
There was no family or personal history of thyroid
disease or of exposure to radiation. Thyroid function test
results were within normal limits. A chest film revealed no

Is hypertension a frequent manifestation of thyroid disease?
Which clinical clues suggest hypertension in persons with thyroid

A 49-year-old woman presented for a
routine eye examination. She had no
history of systemic disease and took
no medications.

A 32-year-old man recently noticed a dark lesion behind his right knee. The patient
denies trauma and fever and has no other medical problems. Since he started working
for the parks and recreation department of the state of Florida 18 months ago, he
has spent an increased amount of time outdoors.

Sudden profound vision loss in her left eye prompted an
82-year-old woman to seek evaluation. She also complained
of “just not feeling well” and reported new-onset
temporal and occipital headaches of 6 weeks’ duration.

During an annual eye examination, a 65-year-old woman
with a 5-year history of type 2 insulin-dependent diabetes
complained that her vision had slightly worsened in both
eyes. Her best corrected visual acuity was 20/30 in both

Until recently, celiac disease
was considered a rare disorder.
However, new evidence
suggests that about
1% of Americans are affected.
As serologic tests that detect autoantigens
involved in celiac disease
become more widely used, more
cases will likely be identified.1

Long-standing chorioretinal scarring in both eyes did
not affect a 67-year-old woman’s vision. The scars were
roundish, irregular, and yellowish white with interior pigmentation
(A and B).

ABSTRACT: The key factor in reducing morbidity
and mortality in patients with chronic
obstructive pulmonary disease (COPD)
continues to be smoking cessation. Newer
formulations of nicotine replacement
therapy—a nasal spray and an inhaler—
provide rapid delivery of nicotine and may
be appropriate for highly dependent smokers.
Bupropion has been shown to improve
smoking cessation rates, either when used
alone or with a nicotine patch. Both the
influenza and pneumococcal vaccines are
recommended to reduce the morbidity and
mortality associated with respiratory infections
in patients with COPD.

An 87-year-old woman complained of
seeing a red tinge on the wallpaper in
her house through her right eye. The
patient had mild memory loss and
moderate hypertension, for which
she took atenolol. She had quit smoking
cigarettes many years earlier.

An 85-year-old man was admitted to the hospital with a
cough and shortness of breath of 1 week’s duration and
a fever and increased sputum production for 2 days. His
history included renal cell carcinoma and metastatic renal
cancer for 2 years. The patient had smoked cigarettes
for 30 years. He had lost 30 lb during the last few months.
A chest film revealed pneumonia of the right lower
lobe. Metastatic nodules were noted on the scalp; extensive
lung, bone, and brain metastases also were found.

An 86-year-old woman had noted intermittent, transient “shading” and “hazing” of the vision in her right eye. Her best corrected vision in that eye was 20/20. She had pseudophakia from past cataract surgery.

Vague abdominal pain, malaise, anorexia,
and the loss of 10 lb in 2
months prompted a 65-year-old man
to seek medical evaluation. A year
earlier he had undergone surgery for
stage III carcinoma of the sigmoid
colon. Because metastases to the
lymph nodes were found in the resected
colon, the patient was given postoperative
chemotherapy. Histologic
examination revealed poorly differentiated

My patient is a 7-year-old girl with multiple plantar warts on both feet.

In his article “High-Risk Hypertensive Patients: How to Optimize Therapy Using
ACE Inhibitors and ARBs” (CONSULTANT, October 2003, page 1390), Dr Jan
Basile recommends angiotensin-converting enzyme (ACE) inhibitors for patients
with type 1 diabetes with or without hypertension, whether or not nephropathy
is present.

In her response to a reader’s question about clot prevention in a patient with systemic
lupus erythematosus (SLE) and anticardiolipin antibody syndrome,
Dr Bonnie Bermas recommends warfarin (CONSULTANT, September 15, 2003,
page 1329).

Signs and symptoms that strongly suggest peripheral arterial occlusive disease include diminished or absent pedal pulses, a unilaterally cool limb, and atrophic skin that is shiny and hairless. An ankle-brachial index of less than 0.5 suggests multisegment disease. Management goals are to decrease functional impairment, treat underlying atherosclerosis, and control risk factors. Smoking cessation is imperative. A graduated walking program is a mainstay of treatment and is associated with greater improvement in pain-free walking than is drug therapy. Surgery and percutaneous intervention are generally reserved for patients with lifestyle-limiting claudication, ischemic pain at rest, tissue loss, or gangrene.

Currently, the only approved therapy for acute ischemic stroke is tissue plasminogen activator (tPA), initiated within 3 hours of stroke onset. New patient selection criteria are emerging that may improve the effectiveness and safety of thrombolysis. For example, evidence of extensive early ischemia on CT may predict a poor outcome regardless of whether tPA is administered. New imaging techniques, such as diffusion MRI, perfusion MRI, and MR angiography, may be able to identify salvageable tissue and distinguish it from irreversibly damaged tissue. Such findings may allow the 3-hour window for tPA therapy to be extended in certain patients. Other approaches to ischemic stroke therapy that are being studied include intra-arterial thrombolysis, new thrombolytic agents, platelet aggregation inhibitors, endovascular interventional techniques (alone and in combination with pharmacologic thrombolysis), and neuroprotective therapy with various agents to ameliorate the consequences of ischemia in brain tissue.

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